All posts by TheTraumaPro

Best Practice: Use of CT Scan In Trauma Activations – Part 1

Computed tomography is an essential part of the diagnostic workup for many trauma patients. However, it’s a limited resource in most hospitals. Only so many scanners are affordable and available.  Typically, trauma centers have a scanner located in or very near the trauma bay, which makes physical access easy. Others may be located farther away, which can pose logistical and safety issues for critically injured patients.

Even if the CT is close to the ED, availability can be an issue. This availability applies not only to trauma scans, but to others as well. There is an expectation that CT be immediately available when needed for trauma activation patients. However, chances are that the same scanner is also used for high priority scans for services other than trauma, such as stroke evaluation.

Who gets the scanner first? Obviously, many trauma patients need rapid diagnosis for treatment of their serious injuries. But a fresh stroke patient also has a neurologic recovery countdown clock running if they might be eligible for lytic administration.

And don’t forget that trauma and stroke aren’t the only services vying for that scanner. The hospital undoubtedly has a stream of elective scans queued up for other in-house patients. Every urgent or emergent scan needed for trauma sets the elective schedule back another 30 minutes or more.

How does your trauma center manage CT scan usage for trauma? The vast majority essentially lock it down at some fixed point. This is typically either upon trauma activation, or at patient arrival. The former is very common, but also very wasteful because there can be a significant wait for the patient to actually arrive. Then add on the time it takes to complete the trauma bay evaluation. Up to an hour may pass, with no throughput in the CT scanner. This can be a major work flow headache for your radiology department.

Is there another way? My center was one of those that stopped the scanner after the current patient was finished at the time the trauma activation was called. We have two scanners just 30 feet from the trauma bays, so one could continue working while the other was held. However, this cut their throughput by 50% for roughly half an hour. We recognized that this was a creating a problem for the whole hospital, so we worked with the radiology department to come up with a better way.

In my next post I’ll detail the new system we implemented, and provide data showing the real impact of this new system on CT scan productivity.

What The Heck?! The Answer!

In my last post, I described an elderly pedestrian struck by a car. During the trauma activation, routine chest and pelvic x-rays were obtained. Here was the pelvic image:

Note the odd oval densities across the center of the x-ray. What the heck? What are they?

There are two choices: they are either inside or outside the patient. We had already removed her clothes, so it wasn’t something she was carrying. And if it was inside, we would be able to identify it on the CT scan we had ordered.

But in this case, the x-ray was done early in the secondary survey. Specifically, we did it before we rolled our patient and examined her back.  When we did, here is what we found:

Only it wasn’t in the box. Or on her neck. This one was stuck on her lower back, but not in her clothes. She was suffering from lower back pain, and applied one of these on a daily basis for comfort. We had not rolled the patient prior to the pelvic x-ray.

The pods on these thermal wraps contain a mixture of iron, sodium chloride, sodium thiosulfate, water, charcoal, and sodium polyacrylate that heat up when removed from their package and exposed to oxygen. The iron renders it somewhat radio-opaque, hence their appearance on the x-ray. We did peel it off prior to CT since it would probably create a significant amount of scatter which would degrade the image.

Should we have waited a few more minutes to get the image until we had rolled and examined the back? This is a judgment call. Since our trauma team moves quickly, we are typically ready to head to the scanner in 15 minutes. In order to improve overall CT scan throughput, we have adopted a 5-minute advance notice policy.  To accomplish this, we don’t want to wait until the very end of the resuscitation to get x-rays. That would end up slowing down our process.

You may feel differently about the timing of the images, or you may have a different method of sequencing your CT scanner. Whatever works best for you. But remember, all trauma patients need to be completely undressed and all of their surfaces, nooks, and crannies inspected before they leave the emergency department!

What The Heck?!

Here’s an interesting case from my image archives.

An elderly female pedestrian was struck by a car. She was hemodynamically stable. During the course of her evaluation as a trauma activation, her clothes were completely removed. (She was kept nice and warm with infrared warmers.)

Early in the secondary survey, chest and pelvic x-rays were obtained. Here is the pelvis image:

What is wrong in this picture?? Leave comments below or tweet your guesses. I’ll publish the answer Friday.

What Is The Safest Extrication Method From A Car Crash?

Today’s post is directed to all those prehospital trauma professionals out there.

Car crashes account for a huge number of injuries world-wide. About 40% of people involved in them are initially trapped in the vehicle. And unfortunately, entrapped individuals are much more likely to die.

There are four basic groups (and their category in parentheses) of trapped car occupants:

  • those who can self-extricate or extricate with minimal assistance (self-extrication)
  • individuals who cannot self-extricate due to pain or their psychological response to the event, but can extricate with assistance (assisted extrication)
  • people who are advised or choose not to self-extricate due to concern for exacerbating an injury, primarily spine (medically trapped)
  • those who are physically trapped by the wreckage who require disentanglement (disentanglement and rescue)

Prehospital providers have several choices to help extricate patients  in the second and third categories: encourage self-extrication, rapid extrication without the use of tools, or traditional extrication where the vehicle is cut away to allow egress. The fourth category always requires tools for extrication.

Although rescue services try to minimize or mitigate unnecessary movement of the patient, stuff happens. Large and forceful movement is considered high risk, but smaller movement do occur. This is of particular concern in patients who might have a spine injury.

There have been a number of recent papers suggesting there might be greater benefits to self-extrication. A group of authors in the UK and South Africa designed a biomechanical study to test these methods of extrication in healthy volunteers.

The authors wanted to find out exactly how much movement occurred using the various extrication techniques. The volunteers were fitted with an Inertial Measurement Unit, which measures the orientation of the head, neck, torso, and sacrum in real time.  The IMU can detect even very small changes in orientation of the body. The volunteers were placed in a standard 5-door hatchback sedans that were prepared for each type of extrication as seen above.

Here are the factoids:

  • A total of 230 extrications were performed for analysis
  • The smallest amount of maximal and total movement of body segments was seen in the self-extrication group
  • The greatest amount of movement was found in the rapid extrication group, with 4x to 5x the movement in the self-extrication group
  • The difference in body movement between the self-extrication group and all others was significant
  • In general, movement increased as extrication techniques progressed from roof removal to B post removal to rapid extrication

The authors concluded that self-extrication resulted in the smallest amount of movement and the fastest extrication time, and that it should be the preferred technique.

Bottom line: This is the first study that specifically evaluated spinal movement occurring with commonly used extrication techniques. Other similar studies have used a variety of measurement techniques, none of which are as precise as this. One potential weakness with this one is that it used healthy volunteers. But obviously, it is not practical to attempt anything like this with real, injured patients. 

Since we know that patients trapped in cars are more likely to die, time is of the essence. This study shows that self-extrication is both fast and safe with respect to spinal movement. The information will assist our prehospital colleagues in making the best decisions possible when faced with patients trapped in their car.

Reference: Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers. Scand J Trauma  open access 30: article 7, 2022.

For PI Fans: Cribari, NFTI, And STAT!

I’ve published a two-part series on the Cribari matrix, Need For Trauma Intervention (NFTI), and the Standardized Triage Assessment Tool (STAT). These are performance improvement topics for the real nerds out there and can be found only on my Trauma PI website, TraumaMedEd.com.

If you are interested in optimizing trauma triage and trauma activations at your center, check out my posts by clicking this link:

https://www.traumameded.com/blog/